Personal Training

PARQ

General Health Questions.
Please read the 8 questions below carefully and answer each one honestly: check YES or NO
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Post code
Telephone Number*
Email*
example@example.com
Date of Birth *

DayMonthYear
1) Has your doctor ever said that you have a heart condition OR high blood pressure?*

YesNo
2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*

YesNo
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?*

YesNo
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

YesNo
5) Are you currently taking prescribed medications for a chronic medical condition?*

YesNo
6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?*

YesNo
7) Are you pregnant or have you had a baby in the last six months?*

YesNo
8) Has your doctor ever said that you should only do medically supervised physical activity?*

YesNo
If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION. You do not need to complete Page 2.

Start becoming much more physically active - start slowly and build up gradually.
PARTICIPANT DECLARATION

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearence is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the personal trainer/fitness centre will retain a copy of this form for its records. In these instances, it will mantain the confidentiality of the same, complying with applicable law.
Signature*

Clear
Date*

DayMonthYear
If you answered YES to one or more of the questions above, PLEASE COMPLETE PAGE 2. Request this page from your personal trainer or await further instructions after the form is reviewed.
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PARQ

Please read the 8 questions below carefully and answer each one honestly: check YES or NO